Method for treatment and prevention of deficiencies of vitamins B12, folic acid and B6

ABSTRACT

A method for orally administering vitamin preparations is described which combine vitamin B 12  (B 12 , cobalamin) and folic acid (folate), with and without pyridoxine (B 6 ), for preventing and treating elevated serum homocysteine (HC), cystathionine (CT), methylmalonic acid (MMA), or 2-methylcitric acid (2-MCA) levels. These metabolites have been shown to be indicative of B 12  and/or folic acid deficiencies. Further, it is likely that a B 6  deficiency may be present with a B 12  or folate deficiency. The method of the invention is also for use in lowering serum HC, CT, MMA, or 2-MCA in patients with or at risk for neuropsychiatric, vascular, renal or hematologic diseases. One embodiment of the invention is the use of a non-prescription formulation containing 2.0 mg B 12  and 0.4 mg folic acid, with and without 25 mg B 6 . Another embodiment uses a prescription strength formulation containing 2.0 mg B 12  and 1.0 mg folic acid, with and without 25 mg B 6 . The method of the present invention eliminate the costly and time consuming steps of distinguishing between vitamin deficiencies once a deficiency is found by measurement of serum metabolite levels. The present invention is of particular benefit to the populations at risk for elevated serum metabolite levels, such as the people over the age of 65, and populations that have or are at risk for neuropsychiatric, vascular, renal and hematologic diseases.

This application is a divisional of application Ser. No. 07/999,499filed Dec. 29, 1992, now U.S. Pat. No. 5,563,126.

FIELD OF THE INVENTION

This invention relates to the field of nutrition. Specifically, theinvention is comprised of new oral vitamin preparations combiningvitamin B₁₂ (B₁₂, cobalamin) and folic acid (folate), and vitamin B₁₂,folate, and pyridoxine (B₆) for use in patients with elevated serummetabolite levels of homocysteine (HC), cystathionine (CT),methylmalonic acid (MMA), or 2-methylcitric acid (2-MCA). The elevationof these metabolites has been shown to be indicative of tissuedeficiencies of B₁₂ and/or folate and/or B₆, and related to increasedrisk of neuropsychiatric, vascular, renal and hematologic diseases. Oneembodiment of the present invention uses a non-prescription formulationcomprising between 0.3-10.0 mg B₁₂ and 0.1-0.4 mg folate, with thepreferred embodiment using 2.0 mg B₁₂ and 0.4 mg folate. Anotherembodiment of the non-prescription formulation uses 0.3-10 mg B₁₂,0.1-0.4 mg folate, and 5-75 mg B₆, with the preferred embodiment using2.0 mg B₁₂, 0.4 mg folate, and 25 mg B₆. Another embodiment of thepresent invention uses a prescription strength formulation comprisingbetween 0.3-10.0 mg B₁₂ and 0.4-1.0 mg folate, with the preferredembodiment using 2 mg B₁₂ and 1.0 mg folate. In a further embodiment ofthe present invention, a prescription strength formulation is usedcomprising 0.3-10 mg B₁₂, 0.4-1.0 mg folate, and 5-75 mg B₆, with thepreferred embodiment using 2 mg B₁₂, 1.0 mg folate, and 25 mg B₆. Theformulations of the present invention eliminate the costly andtime-consuming steps of distinguishing between vitamin deficiencies oncea deficiency is found by measurement of serum metabolite levels. Thepresent invention is of particular benefit to the populations at riskfor tissue deficiencies of B₁₂, folate, and B₆, such as people over theage of 65, and populations that have or are at risk forneuropsychiatric, vascular, renal and hematologic diseases.

BACKGROUND

Vitamins B₁₂, folate, and B₆ are required cofactors in metabolicpathways involving methionine, homocysteine, cystathionine, andcysteine. B₁₂ in the form of 5'-deoxyadenosylcobalamin is an essentialcofactor in the enzymatic conversion of methylmalonylCoA to succinylCoA.The remethylation of homocysteine (HC) to methionine catalyzed bymethionine synthase requires folate (methyltetrahydrofolate) and B₁₂ inthe form of methylcobalamin. HC is condensed with serine to formcystathionine (CT) in a reaction catalyzed by cystathionine β-synthasewhich requires B₆ (pyridoxal phosphate). CT is hydrolyzed in another B₆-dependent reaction to cysteine and α-ketobutyrate.

It is important to diagnose and treat B₁₂, folate, and B₆ deficienciesbecause these deficiencies can lead to life-threatening hematologicabnormalities which are completely reversible by proper treatment. B₁₂deficiency is a multisystem disorder with extremely varied clinicalpresentation which has been thought to occur in 0.4% of the population,e.g., about 1 million people in the United States. Symptoms of B₁₂deficiency include significant anemia, displayed for example indecreased hematocrit (e.g., <25%) or hemoglobin (e.g., ≦8 g %), withmacrocytic red blood cells (i.e., mean cell volume generally greaterthan 100 fl), or neurologic symptoms of peripheral neuropathy and/orataxia. See, for example, Babior and Bunn (1983) in Harrison'sPrinciples of Internal Medicine, (Petersdorf et al., eds.), McGraw-HillBook Co., New York; Lee and Gardner (1984) in Textbook of FamilyPractice. 3rd Ed. (Rakel, ed.), Saunders & Co., Philadelphia). Thehematological abnormalities seen are due to intracellular folatedeficiency since folate is required for a number of essential enzymaticreactions involved in DNA and RNA synthesis and since the form of folatein serum (5-methyltetrahydrofolate) must be metabolized totetrahydrofolate by the B₁₂ -dependent enzyme methionine synthase beforeit can be utilized by the RNA- and DNA-related enzymes. While it hasbeen well recognized that individuals with B₁₂ deficiency could displayneurologic disorders in the absence of anemia, such situations werebelieved to be exceptional and rare. See, Beck (1985) in Cecil Textbookof Medicine, 17th Ed., (Wyngaarden and Smith, eds.), W. B. Saunders,Philadelphia, pp. 893-900; Babior and Bunn (1987) in Harrison'sPrinciples of Internal Medicine, 11th Ed., (Braunwald et al., eds.)McGraw-Hill, New York, pp. 1498-1504; Walton (1985) in Brain's Diseasesof the Nervous System, 9th Ed., Oxford University Press, Oxford, UK. Theneurologic symptoms of B₁₂ deficiency were considered to be latemanifestations of the disease most typically occurring after the onsetof anemia or, if they occurred first, were soon to be followed by theonset of anemia. See, Woltmann (1919) Am. J. Med. Sci. 157:400-409;Victor and Lear (1956) Am. J. Med. 20:896-911.

However, it has recently been shown that the textbook description ofsevere megaloblastic anemia and combined systems disease of the nervoussystem is the rarest presentation of B₁₂ deficiency at the present time(Stabler et al. (1990) Blood 76:871-881; Carmel (1988) Arch. Int. Med.148:1712-1714; Allen (1991) in Cecil Textbook of Medicine, 19th Ed.,(Wyngaarden and Smith, et al. eds.), W. B. Saunders, Philadelphia, pp.846-854.). Therefore, contrary to previous teachings, patients that maybenefit from B₁₂ therapy may have minimal to no hematologic changeswhile manifesting a wide variety of neurologic and psychiatricabnormalities (Lindenbaum et al. (1988) N. Engl. J. Med. 318:1720-1728;Greenfield and O'Flynn (1933) Lancet 2:62-63). This is particularly truefor populations at risk for B₁₂ deficiency, such as the elderlypopulation (Pennypacker et al. (1992) J. Am. Geriatric Soc. 40: (inpress).

The incidence of folate deficiency in the population is unknown, but hasbeen thought to occur commonly in individuals with various degrees ofalcoholism. The hematologic abnormalities seen with folate deficiency,such as macrocytic anemia, are indistinguishable from those seen withB₁₂ deficiency. Folate is required for a number of essential enzymaticreactions involved in DNA and RNA synthesis, and is particularlyimportant in rapidly dividing cells like those in the bone marrow.

B₆ is required for the first step in heme synthesis and serves a majorrole in transamination reactions of amino acid metabolism, indecarboxylations, and in the synthesis of the neuroactive amineshistamine, tyramine, serotonin, and γ-aminobutyric acid (GABA). Clinicalmanifestations include microcytic hypochromic anemia, characteristicskin changes of dermatitis and acrodynia, muscular weakness, and avariety of neuropsychiatric abnormalities including hyperirritability,epileptiform confusions, depression and confusion (Newberne and Conner(1989) in Clinical Biochemistry of Domestic Animals, Academic Press, SanDiego, pp. 796-834).

Vitamin deficiencies are generally determined by measurement of serumlevels. Normal serum B₁₂ levels are 200-900 pg/ml, with levels of lessthan 100 pg/ml being said to indicate clinically significant deficiency(Beck (1985) supra) However, serum B₁₂ levels are a relativelyinsensitive determinant of B₁₂ deficiency in that only 50% of patientswith clinically confirmed B₁₂ deficiency have levels less than 100pg/ml, 40% are 100-200 pg/ml, and at least 5-10% have values in the200-300 pg/ml range. Diagnosis is further complicated by the fact that2.5% of normal subjects (6,250,000 people in the U.S.) have low serumB₁₂ levels (Allen (1991) supra), with no evidence of B₁₂ deficiency andare unlikely to benefit from B₁₂ therapy (Schilling et al. (1983) Clin.Chem. 29:582; Stabler (1990) supra).

Normal serum folate levels are 2.5-20 ng/ml, with levels less than 2.5ng/ml indicating the possibility of clinically significant deficiency.Like B₁₂ serum levels, however, serum folate levels are a relativelyinsensitive measure in that only 50-75% of patients with folatedeficiency have levels less than 2.5% ng/ml, with most of the remaining25-50% being in the 2.5-5.0 ng/ml range (Allen (1991) in Cecil Textbookof Medicine, 19th Ed., supra).

The development of sensitive serum metabolite assays for HC, CT, MMA,and 2-MCA has allowed the relationship between metabolite levels andvitamin deficiencies to be investigated (Stabler et al. (1987) Anal.Biochem. 162:185-196; Stabler et al. (1986) J. Clin. Invest.77:1606-1612; Stabler et al. (1988) J. Clin. Invest. 81:466-474). It hasbeen found that elevated serum levels of HC and MMA are clinicallyuseful tests of functional intracellular deficiencies of B₁₂ and folate,with elevated HC levels seen with both B₁₂ and folate deficiencies, andelevated MMA levels seen with a B₁₂ deficiency (Allen et al. (1990) Am.J. Hematol. 34:90-98; Lindenbaum et al. (1990) Am. J. Hematol.34:99-107; Lindenbaum et al. (1988) N. Engl. J. Med. 318:1720-1728; Beck(1991) in Neuropsychiatric Consequences of Cobalamin Deficiency, MosbyYear Book 36:33-56; Moelby et al. (1990) 228:373-378; Ueland and Refsum(1989() J. Lab. Clin. Med. 114:473-501; Pennypacker et al. (1992)supra). Increased serum levels of CT are seen in both deficiencies and2-MCA is elevated in B₁₂ deficiency (Allen et al. (1991) in Proceedingsof the 1st International Congress on Vitamins and Biofactors in LifeScience, Kobe (Japan); Allen et al. (1993) Metabolism (in press)). HCand CT may be elevated in patients with intracellular deficiency of B₆,but this has not been as well documented (Park and Linkswiler (1970) J.Nutr. 100:110-116; Smolin and Benvange (1982) J. Nutr. 112:1264-1272).

Elevated serum metabolite levels are observed in disease states otherthan classic vitamin deficiencies. For example, elevated HC levels havebeen observed in the presence of vascular disease. The homocysteinetheory of -atherosclerosis, formulated by McCully and Wilson (1975)Atherosclerosis 22:215-227, suggests that high levels of HC areresponsible for the vascular lesions seen in homocystinuria, a geneticdefect caused by a deficiency in the enzyme cystathionine β-synthase.The theory also implies that moderate elevations of HC might beassociated with increased risk for vascular disease (Ueland et al.(1992) in Atherosclerotic Cardiovascular Disease, Hemostasis, andEndothelial Function (Francis, Jr., ed.), Marcel Dekker, Inc., New York,pp. 183-236). Moderate hyperhomocysteinaemia has been shown to befrequently present in cases of stroke and to be independent of otherstroke risk factors (Brattstrom et al. (1992) Eur. J. Clin. Invest.22:214-221). Clinical and experimental evidence demonstrates thatpatients who are homozygotes for cystathionine β-synthase deficiencyhave a markedly increased incidence of vascular disease and thrombosis.A number of studies (see, Clarke et al. (1991) N. Engl. J. Med.324:1149-1155) strongly suggest that heterozygotes for a deficiency ofcystathionine β-synthase also have an increased incidence of vasculardisease and thrombosis and that such heterozygotes may constitute asmany as one-third of all patients who develop strokes, heart attacks, orperipheral vascular disease under age 50. It is also likely that suchheterozygotes are also at increased risk for vascular disease andthrombosis after age 50. Since the incidence of heterozygosity forcystathionine β-synthase deficiency is estimated to be 1 in 60-70, thismeans that there are approximately 4 million heterozygotes in the U.S.It is also possible that patients with vascular disease due to othercauses, such as hypercholesterolemia, would also benefit from a decreasein their serum HC levels even if their existing levels are only slightlyelevated or actually within the normal range.

Renal disease is another condition that gives rise to elevated levels ofserum metabolites. Approximately 75% of patients with renal disease haveelevated serum concentrations of HC, CT, MMA, and 2-MCA. Since patientswith renal disease have a significant incidence and marked accelerationof vascular disease, it might be beneficial to lower their serummetabolite levels, especially that of HC.

An increasing prevalence of low serum B₁₂ concentrations with advancingage has been found by many but not all investigators (Bailey et al.(1980) J. Am. Geriatr. Soc. 28:276-278; Eisborg et al. (1976) Acta Med.Scand. 200:309-314; Niisson-Ehle et al. (1989) Dig. Dis. Sci.34:716-723; Norman (1985) 33:374; Hitzhusen et al. (1986) Am. J. Clin.Pathol. 85:3236), folate (Magnus et al. (1982) Scan. J. Haematol.28:360-366; Blundell et al. (1985) J. Clin. Pathol. 38:1179-1184; Elwoodet al. (1971) Br. J. Haematol. 21:557-563; Garry et al. (1984) J. Am.Geriatr. Soc. 32:71926; Hanger et al. (1991) J. Am. Geriatr. Soc.39:1155-1159), and B₆ (Ranke et al. (1960) J. Gerontol. 15:41-44; Roseet al. (1976) Am. J. Clin. Nutr. 29:847-853; Baker et al. (1979) J. Am.Geriatr. Soc. 27:444-450). Moreover, prevalence estimates for thesevitamin deficiencies vary widely depending on the population groupsstudied. It has been unclear whether this increased prevalence is anormal age related phenomena or a true reflection of tissue vitamindeficiency and whether the low serum vitamin concentrations are areliable indicator of functional intracellular deficiency.

It is difficult, expensive and time-consuming to distinguish betweendeficiencies of vitamins B₁₂, folate, and B₆. The hematologicabnormalities seen with B₁₂ deficiency are indistinguishable from thoseseen with folate deficiency. Similarly to a B₁₂ deficiency, B₆deficiencies also result in hematologic as well as neuropsychiatricabnormalities. The traditional methods of determining deficiencies bymeasurement of serum vitamin levels are often insensitive. As a result,in order to determine if and which vitamin deficiency is present, apatient will be treated with one vitamin at a time and the response tothat vitamin determined by normalization of serum vitamin levels and thecorrection of hematologic abnormalities. These steps are then repeatedwith each vitamin. This method of treatment is both expensive andtime-consuming. In the presence of multiple deficiencies, the diagnosisof vitamin deficiencies is further confused and give rise to thedangerous possibility that only one deficiency will be treated. Forexample, the hematologic abnormalities seen with a B₁₂ deficiency willrespond to treatment with folate alone. However, the neuropsychiatricabnormalities caused by the B₁₂ deficiency will not be corrected and mayindeed by worsened.

It has now been discovered for the first time that the prevalence ofintracellular deficiencies of vitamins B₁₂, folate, and B₆, alone or incombination, is substantially higher than that previously estimated bymeasurement of serum vitamin concentrations. The present disclosureestablishes that tissue deficiencies of one or more of the vitamins B₁₂,folate and B₆, as demonstrated by the elevated metaboliteconcentrations, occurs commonly in the elderly population even whenserum vitamin levels are normal. Based on this new discovery, thepresent invention addresses the problem of distinguishing betweenvitamin deficiencies when low, low-normal, or normal serum vitaminconcentrations are found by providing formulations for the treatment ofhigh serum metabolites and at-risk populations for combinations of oneor more tissue deficiencies of vitamins B₁₂, folate, and B₆.

Hathcock and Troendle (1991) JAMA 265:96-97, have suggested thetreatment of pernicious anemia with an oral pill containing 300 to 1000ug or more per day of B₁₂. However, contrary to the present invention,Hathcock and Troendle teach away from combining B₁₂ therapy with folate,since "if the oral cobalamin therapy should fail to maintain adequatelevels, folate might provide protection against development of anemiawhile permitting nerve damage from cobalamin deficiency."

U.S. Pat. No. 4,945,083, issued Jul. 31, 1990 to Jansen, entitled: SafeOral Folic-Acid-Containing Vitamin Preparation, describes a oral vitaminpreparation comprising 0.1-1.0 mg B₁₂ and 0.1-1.0 mg folate for thetreatment or prevention of megaloblastic anemia. This formulationpresents a problem in the case of a B₁₂ deficient patient, in that the0.5 mg folate may correct the hematologic abnormalities present, but the0.5 mg B₁₂ dose may be insufficient to correct a B₁₂ deficiency due toinadequate intrinsic factor. By contrast, the formulation of the presentinvention teaches the use of the combination of B₁₂ and folate, and ofB₁₂, folate and B₆, sufficient to treat either single or multipledeficiencies of B₁₂ folate, and B₆. The present invention does not relyon the determination of vitamin deficiencies by the measurement of serumvitamin levels, but uses the more sensitive measurement of elevatedserum metabolites of HC, CT, MMA, and 2-MCA, shown to be related to thepresence of B₁₂ and/or folate and/or to B₆ deficiencies or to thepresence of the increased risk of neuropsychiatric, vascular, renal, andhematologic diseases.

It is to be understood that both the foregoing general description andthe following detailed description are exemplary and explanatory onlyand are not restrictive of the invention as claimed.

SUMMARY OF THE INVENTION

This invention includes a method for orally administering two newvitamin preparations containing vitamin B₁₂ and folate, and vitamin B₁₂,folate and B₆, for the treatment of patients with elevated serummetabolites, such as homocysteine, cystathionine, methylmalonic acid,and 2-methylcitric acid, as well as populations at risk for tissuedeficiencies in one or more of the vitamins B₁₂, folate, and B₆ or forneuropsychiatric, vascular, renal, or hematologic diseases.

One embodiment of the present invention is uses an over-the-counterformulation comprised of between 0.3-10 mg CN-cobalamin (B₁₂) and0.1-0.4 mg folate. Another embodiment of the non-prescriptionformulation uses 0.3-10 mg B₁₂, 0.1-0.4 folate, and 5-75 mg B₆.Preferred embodiments of the over-the-counter formulation are comprisedof about 2.0 mg B₁₂ and 0.4 mg folate, and 2.0 mg B₁₂, 0.4 mg folate,and 25 mg B₆, respectively.

Another embodiment of the present invention uses a prescriptionformulation comprised of between 0.3-10 mg CN-cobalamin (B₁₂) and0.4-10.0 mg folate. Another embodiment of the prescription formulationof the present invention uses 0.3-10 mg B₁₂, 0.4-1.0 mg folate, and 5-75mg B₆. Preferred embodiments of the prescription formulation use about2.0 mg B₁₂ and 1.0 mg folate, and 2.0 mg B₁₂, 1.0 mg folate, and 25 mgB₆, respectively.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows the distribution of serum B₁₂ levels for a population ofelderly outpatients (ages 65-99, n=152) and a normal population (ages17-65, n=100).

FIG. 2 shows serum MMA levels for a population of elderly outpatientswith serum B₁₂ values <300 pg/ml (ages 65-99, n=38/152) and a normalpopulation with serum B₁₂ values <300 pg/ml (ages 17-65, n=10/100).

FIG. 3 shows serum HC levels for a population of elderly outpatientswith serum B₁₂ values <300 pg/ml (ages 65-99, n=38/152) and a normalpopulation with serum B₁₂ values <300 pg/ml (ages 17-65, n=10/100).

FIG. 4 shows serum MMA levels before and after treatment with parenteralcobalamin for a population of elderly outpatients with elevated MMAvalues and serum B₁₂ values <300 pg/ml (ages 65-99, n=15/38).

FIG. 5 shows serum HC levels before and after treatment with parenteralcobalamin for a population of elderly outpatients with elevated HCvalues and serum B₁₂ values of <300 pg/ml (ages 65-99, n=10/38).

FIG. 6 shows the distribution of serum B₁₂ levels for a population ofelderly nursing home patients (ages 55-107, n=212) and a normalpopulation (ages 17-65, n=100).

FIG. 7 shows serum MMA levels for a population of elderly nursing homepatients with serum B₁₂ values <300 pg/ml (ages 55-107, n=29/212) and anormal population with serum B₁₂ values (ages 17-65, n=10/100).

FIG. 8 shows serum HC levels for a population of elderly nursing homepatients with serum B₁₂ values <300 pg/ml (ages 55-107, n=29/212) and anormal population with serum B₁₂ values <300 pg/ml (ages 17-65,n=10/100).

FIG. 9 shows serum MMA levels before and after treatment with parenteralcobalamin for a population of elderly nursing home patients with serumB₁₂ values <300 pg/ml (ages 55-107, n=14/29).

FIG. 10 shows serum HC levels before and after treatment with parenteralcobalamin for a population of elderly nursing home patients with serumB₁₂ values <300 pg/ml (ages 55-107, n=14/29).

FIG. 11 shows the distribution of serum B₁₂ levels for a population ofelderly patients (ages 65-99, n=548) and a normal population (ages22-63, n=117) (Framingham study).

DETAILED DESCRIPTION OF THE INVENTION

Reference will now be made in detail to the presently preferredembodiments of the invention, which, together with the followingexamples, serve to explain the principles of the invention.

This invention uses new oral vitamin formulations combining vitamin B₁₂(B₁₂, cobalamin) and folic acid (folate), and vitamin B₁₂ folate andpyridoxine (B₆) The formulations of the present invention are for use inthe treatment of elevated serum levels of one or more the metaboliteshomocysteine (HC), cystathionine (CT), methylmalonic acid (MMA), or2-methylcitric acid (2-MCA). The use of the formulations of the presentinvention further include as a method of lowering serum metaboliteslevels of one or more of HC, CT, MMA, or 2-MCA, where these metabolitelevels are not elevated but the patients are at risk for or haveneuropsychiatric, vascular, renal, or hematologic diseases.

One embodiment of the present invention uses a non-prescriptionformulation comprised of between about 0.3-10 mg CN-cobalamin (B₁₂) and0.1-0.4 mg folate. Another embodiment of the present invention uses anon-prescription formulation comprised of between about 0.3-10 mg B₁₂,0.1-0.4 mg folate, and 5-75 mg B₆. Preferred embodiments of thenon-prescription formulation are comprised of about 2.0 mg B₁₂ and 0.4mg folate, and 2.0 mg B₁₂, 0.4 mg folate, and 25 mg B₆, respectively.

Another embodiment of the present invention is comprised of aprescription formulation comprised of between about 0.3-10 mg B₁₂ and0.4-10.0 mg folate, with the preferred embodiment comprised of about 2.0mg B₁₂ and 1.0 mg folate. Another embodiment of the prescriptionstrength formulation is comprised of about 0.3-10 mg B₁₂, 0.4-10.0 mgfolate, and 5-75 mg B₆, with a preferred embodiment comprised of about2.0 mg B₁₂, 1.0 mg folate, and 25 mg B₆.

The formulations of the present invention are for the treatment andprevention of elevated metabolite levels in at risk populations, such asthe elderly, and people that have or are at risk for neuropsychiatric,vascular, renal and hematologic diseases. The present inventioneliminates the costly and time consuming need to differentiate betweenB₁₂, folate, and B₆ deficiencies.

The administration of a daily dose of the vitamin formulations of thepresent invention provides better long-term normalization of serum HCand other metabolites than prior art formulations, and eliminates thedifficulty in differentiating between deficiencies of two or three ofthe vitamins, the difficulty in diagnosing multiple deficiencies of twoor three of the vitamins, and the expense of doing so. Further, theadministration of an oral preparation of B₁₂ and folate, with or withoutB₆, is preferred over intramuscular injections for patient convenienceand ease of administration.

For example, the inclusion of B₁₂ will be useful as a safeguard forpatients misdiagnosed as folate deficient, even though they are actuallyB₁₂ deficient, since treatment with folate alone in such patients isextremely dangerous. The danger arises from the fact that treating a B₁₂deficient patient with folate alone may reverse or prevent thehematologic abnormalities seen in B₁₂ deficiency, but will not correctthe neuropsychiatric abnormalities of a B₁₂ deficiency and may actuallyprecipitate them. Even in the absence of intrinsic factor, approximately1% of a 2.0 mg oral dose of B₁₂ is absorbed by diffusion. Thus,approximately 20 ug of B₁₂ would be absorbed from the formulations ofthe present invention which would be more than adequate even in patientswith pernicious anemia who have lost their intrinsic factor-facilitatedabsorption mechanism for B₁₂. The inclusion of folate will be of benefitsince B₁₂ deficiency causes a secondary intracellular deficiency offolate. The inclusion of folate and B₆ will also be of benefit inpatients with mixed vitamin deficiencies.

The formulations of the present invention may be administered as anon-injectable implant or orally. Non-injectable use may be as a patch.Formulations for oral administration are preferably encapsulated.Preferably, the capsule is designed so that the formulation is releasedgastrically where bioavailability is maximized. Additional excipientsmay be included to facilitate absorption of the vitamin formulations.Diluents, flavorings, low melting point waxes, vegetable oils,lubricants, suspending agents, tablet disintegrating agents, and bindersmay also be employed.

Example 1 describes the methods used to measure serum vitamin andmetabolite levels. Example 2 describes a new study conducted with 412subjects over the age of 65 with a variety of medical conditionscorrelating the incidence of low serum vitamin levels with elevatedserum metabolite levels. A study determining the incidence of undetectedB₁₂ deficiency and response of serum MMA and HC to B₁₂ treatment in ageriatric outpatient population is described in Example 3. Example 4describes a similar study conducted with a geriatric nursing homepopulation, and Example 5 describes a similar study conducted withanother geriatric population.

EXAMPLE 1. Methods for Measurement of Serum Vitamin and MetaboliteLevels.

Serum vitamin assays. Serum vitamins B₁₂ and folate were measured by aquantitative radioassay method using purified intrinsic factor andpurified folate binding protein. Vitamin B₆ was measured by aradioenzymatic assay method wherein serum is incubated with apoenzymetyrosine-decarboxylase, C₁₄ labelled tyrosine is added to start theenzymatic reaction which is stopped with HCl. Subsequently the free C₁₄-labelled CO₂ is adsorbed by a KOH impregnated filtering paper. Themeasured C₁₄ activity is directly proportional to the B₆ (pyridoxalphosphate) concentration (Laboratory Bioscientia, Germany).

Serum metabolite assays. Serum metabolite assays for homocysteine andmethylmalonic acid were conducted by the capillary gas chromatographyand mass spectrometry methods of Marcell et al. (1985) Anal. Biochem.150:58; Stabler et al. (1987) supra, and Allen et al. (1990) Am. J.Hematol. 34:90-98. Serum cystathionine levels were assayed by the methodof Stabler et al. (1992) Blood (submitted). Serum 2-methylcitric acidwas assayed by the method of Allen et al. (1993) Metabolism supra.

Statistical methods. Statistical analysis was done with the SASstatistical package (version 6.06). Nonparametric data for two or moregroups were tested with the two sample Wilcoxon rank sum test (withBonferroni's correction for the significance level α) and the KruskallWallis test. From the result of the healthy young subjects referenceintervals were calculated. Since the frequency distribution of thevalues of each parameter were markedly abnormal they were transformed tonormal distributions using log transformation. The sample prevalence pwith 95% confidence intervals of low serum vitamins B₁₂, folate, and B₆concentrations was calculated as (p±2 p (1-p)/n×100 wherein n is thetotal sample size, p is the number of low serum vitaminconcentrations/n; low serum concentrations are defined as <mean--2 S.D.

EXAMPLE 2. Incidence of Elevated MMA, 2-MCA. HC, and CT Levels in theGeriatric Population.

The serum concentrations of B₁₂, folate, and B₆ were measured in 412subjects over the age of 65 (subgroups A-D), and in 99 healthy controlsubjects aged 20-55 years (subgroup E). The geriatric subgroups weredefined as follows: A, 110 patients with atherosclerosis; B, 98 patientswith neuropsychiatric disorders; C, 102 patients with atherosclerosisand multiple diseases including rheumatoid arthritis and diabetes; D,102 subjects who were healthy.

Venous blood was obtained from all subjects in the morning after anovernight fast. The blood was spun within one hour after collection andthe serum was transported in dry ice to the central laboratory. Serumvitamins B₁₂ and folate were measured as described in Example 1 with avitamin B₁₂ /folate dual RIA kit (CT301/CT302 Amersham Buchier, UK).Vitamin B₆ and serum metabolites were measured as described in Example1.

Since renal function can influence serum metabolite concentrations(Ueland and Refsum (1989) supra; Moelby et al. (1992) Scand. J. Clin.Lab. Invest. 52:351-354), serum creatinine concentrations were measuredin all subjects by the Jaffe photometric method (Laboratory Bioscientia,Germany). Normal range was 62-124 μmol/L. Creatine clearance wascalculated using the formulation of Cockroft and Gault (1976) Nephron16:31-41.

Normal ranges for serum vitamin and metabolite levels were determined bythe mean +2 standard deviations after log normalization using the valuesfrom subgroup E. Results are shown in Table 1:

                  TABLE 1                                                         ______________________________________                                        INCIDENCE OF LOW SERUM VITAMIN AND HIGH                                       METABOLITE LEVELS IN GERIATRIC POPULATIONS A-D AND A                          YOUNGER HEALTHY POPULATION E.                                                              Folic                                                            Group B.sub.12                                                                             Acid    B.sub.6                                                                            MMA    2-MCA HC    CT                               ______________________________________                                        A     6%     12%     48%  36%    44%   55%   64%                              B     6%     19%     53%  47%    39%   59%   66%                              C     3%     10%     50%  32%    45%   39%   73%                              D     6%      6%     17%  26%    23%   38%   41%                              E     2%      1%      1%   3%     6%    2%    4%                              ______________________________________                                    

There was a rough correlation with low vitamin levels and elevatedmetabolites, but many of the patients with elevated metabolites had lownormal or normal vitamin levels. Correlations between clinicalabnormalities within groups A, B, and C were not present. Patients weretreated with weekly injections of a multi-vitamin preparation containing1.0 mg B₁₂, 1.1 mg folate, and 5 mg B₆, resulting in a marked loweringor normalization of elevated metabolite levels in virtually everyelderly patient.

These data support the conclusions that there is an increased incidenceof low levels of serum B₁₂, folate, and B₆ in the geriatric population,and that serum MMA, 2-MCA, HC and CT are elevated in an even higherpercentage of geriatric patients. The presence of elevated levels of oneor more of the metabolites HC, CT, MMA, or 2-MCA indicate a tissue orintracellular deficiency of one or more of the vitamins B₁₂, folate andB₆. It not possible to tell without expensive, time-consuming, andextensive testing which one vitamin or pair of vitamins, or whether allthree vitamins are deficient. These observations, together with the factthat elevated metabolite levels are corrected by parenteral therapy witha combination of vitamins B₁₂, folate, and B₆, indicate that a tissuedeficiency of one or more of these vitamins occurs commonly in thegeriatric population and that measurement of serum vitamin levels aloneis an inadequate method for identifying such deficiencies.

EXAMPLE 3. Determination of Serum B₁₂, Folate, MMA, HC, CT and 2-MCALevels in a Geriatric Outpatient Population.

A study was conducted with 152 elderly outpatient subjects to measurethe prevalence of B₁₂ deficiency in geriatric outpatients as determinedby both low serum B₁₂ levels and elevations of MMA and HC, and todetermine the response to B₁₂ treatment. Blood samples were obtained on152 consecutive geriatric outpatients, ages 65-99. Control values weredetermined from 100 subjects, ages 17-65. Serum B₁₂, folate, MMA, HC,CT, and 2-MCA levels were obtained for each patient, shown in Table 2.The significance of the results marked as "**" in Table 2 are asfollows: B₁₂ levels of <200 pg/ml; folate <3.8 ng/ml; homocysteine >16.2uM; MMA >271 nM; CT >342 nM; and 2-MCA >228 nM. Serum MMA, HC, CT, and2-MCA levels were measured as described in Example 1. Serum B₁₂ andfolate were measured as described in Example 1 using a Corning Immophasekit (CIBA-Corning, Medfield, Mass.) with the normal range defined as200-800 pg/ml for B₁₂ and 3.8 ng/ml for folate. After evaluation,patients received weekly parenteral cyanocobalamin injections (1,000 ugIM) for 8 weeks, followed by monthly injections. Repeat laboratory andclinical assessments were administered at 8 weeks and at 6 months.

Results show that 25% of the subjects had a serum B₁₂ level ≦300 pg/mland 8.5% had a low level of <200 pg/ml. FIG. 1 shows the shift seen inelderly subject towards lower serum B₁₂ levels. More than half of thesubjects with low or low-normal serum B₁₂ levels had elevations of MMA(FIG. 2) and/or HC (FIG. 3) greater than 3 S.D. above the means innormals and representing 14.5% of the total screened population.

Patients with low and low/normal serum B₁₂ levels were treated withweekly injections of 1.0 mg B₁₂. Parenteral B₁₂ administration causedelevated metabolite levels to fall to or towards normal (FIGS. 4 and 5)in every subject treated with B₁₂. It appears that the true prevalenceof previously unrecognized B₁₂ deficiency in this elderly populationswas at least 14.5%.

It can be seen from the data presented in Table 2 that serum B₁₂ levelsare insensitive for screening B₁₂ deficiencies since similar numbers ofpatients with low normal serum B₁₂ levels of 201-300 pg/ml compared withpatients with low B₁₂ levels (≦200 pg/ml) had markedly elevatedmetabolites which fell with B₁₂ treatment. Further, this study showsthat elderly patients have a high incidence (at least 14.5%) ofunrecognized B₁₂ deficiency, detectable by measurement of serum HC andMMA levels in patients with serum B₁₂ levels <300 pg/ml.

A further finding in this study emphasizes the need to treat elevatedmetabolite levels with a combination of vitamin B₁₂ and folate with orwithout B₆. Some of the patients exhibiting elevated metabolite levelsdid not fully respond to B₁₂ treatment. This may indicate a concomitantdeficiency of folate and/or B₆. The lack of response to B₁₂ treatmentcould result from a deficiency of one, a pair, or all three vitamins.However, it would be expensive and time-consuming to attempt todistinguish between the vitamin deficiencies.

Another, and perhaps the most important, finding in this study is thelarge number of patients with serum B₁₂ >300 pg/ml who have elevatedvalues for one or more metabolites as indicated by a "**" next to theindividual values. As can readily be seen in Table 2, there are manyexamples of elevated value for MMA and/or 2-MCA at all levels of serumB₁₂ including the mid-normal (300-600 pg/ml), the high-normal (600-800pg/ml), and even the elevated (>800 pg/ml) ranges. The same is true forelevations of HC and CT. In some patients the serum folate is low,indicating that folate deficiency may be present, but in many cases bothB₁₂ and folate levels are normal. B₆ levels were not performed in thisstudy, but B₆ deficiency would not be expected to cause elevations ofMMA or 2-MCA. Thus in many patients it is not clear which vitamin, orpair of vitamins, or whether all three vitamins is or are deficient. Onecould pick a single vitamin, often at random, with which to treat apatient for several weeks or months, and then repeat measurement ofmetabolite levels to determine if a partial or full correction hadoccurred. If there was no response, one could try another vitamin, or ifthere was a partial response one could add a second vitamin, and thenrepeat metabolite measurement after several weeks or months. If therewas still no response, one could try the third vitamin, or if there wasa partial response, one could try a different pair of vitamins.Eventually one could determine whether an individual vitamin, aparticular pair of vitamins, or all three vitamins were required tonormalize or maximally reduce the metabolite levels, but it would oftenrequire months or even a year to make this determination. Such adetermination would be expensive. In addition, a patient who wasoptimally treated with a single vitamin or pair of vitamins mightsubsequently develop a deficiency of one or even two of the othervitamins as evidenced by a re-elevation or increase in the levels of oneor more metabolites. Therapeutic testing could be reinitiated andcontinued as described above, although this would also be time-consumingand expensive.

It requires less time and expense to treat patients with elevatedmetabolite levels with a combination of vitamin B₁₂ and folate, or acombination of vitamin B₁₂ folate and vitamin B₆. The utility of theapproach of the present invention is appreciated only after it istaught, for the first time in the present disclosure, that a deficiencyof one or more of the three vitamins occurs commonly in the elderlypopulation as evidenced by elevation of one or more metabolites, i.e.,MMA, 2-MCA, HC and CT.

EXAMPLE 4. Determination of Serum B₁₂, Folate, MMA, and HC Levels in aGeriatric Nursing Home Population.

A study was conducted with 212 elderly nursing home patients todetermine serum B₁₂, folate, MMA, and HC levels (Table 3). Thesignificance of the results shown in Table 3 marked with "**" are asdescribed for Table 2 (Example 3). The control group consisted of 100subjects between the ages of 17-65 years. As in the study described inExample 3, the elderly population exhibited a shift to lower serum B₁₂levels (FIG. 6), elevated serum MMA (FIG. 7) and HC (FIG. 8) levels.Parenteral administration of B₁₂ 1 mg per week for 8 weeks to those withserum B₁₂ <300 pg/ml caused elevated MMA (FIG. 9) and HC (FIG. 10)levels to fall to or towards normal.

As in the study reported in Example 3, a further finding in this studyemphasizes the need to treat elevated metabolite levels with acombination of vitamins B₁₂ and folate, with or without B₆. Some of thepatients exhibiting elevated metabolite levels did not fully respond toB₁₂ treatment. This may indicate a concomitant deficiency of folateand/or B₆. The lack of response to B₁₂ treatment could result from adeficiency of one, a pair, or all three vitamins. However, it would beexpensive and time-consuming to attempt to distinguish between thevitamin deficiencies.

Again, an important finding in this study is the large number ofpatients with serum B₁₂ >300 pg/ml who have elevated values for one ormore metabolites as indicated by a "**" next to the individual values.As is seen in Table 3, there are many examples of elevated values forMMA at all levels of serum B₁₂ including the mid-normal (300-600 pg/ml),the high-normal (600-800 pg/ml), and even the elevated (>800 pg/ml)ranges. The same is true for elevations of HC. In some patients theserum folate is low, indicating that folate deficiency may be present,but in many cases both B₁₂ and folate levels are normal. B₆ levels werenot performed in this study, but B₆ deficiency would not be expected tocause elevations of MMA. Thus, again it is not clear which vitamin, orpair of vitamins, or whether all three vitamins is or are deficient. Onecould pick a single vitamin with which to treat a patient for severalweeks or months, and then repeat measurement of metabolite levels todetermine if a partial or full correction had occurred. If there was noresponse, one could try another vitamin, or if there was a partialresponse one could add a second vitamin, and then repeat metabolitemeasurement after several weeks or months. If there was still noresponse, one could try the third vitamin, or if there was a partialresponse, one could try a different pair of vitamins. Eventually onecould determine whether an individual vitamin, a particular pair ofvitamins, or all three vitamins were required to normalize or maximallyreduce the metabolite levels, but it would often require months or evena year to make this determination. Such a determination would beexpensive. In addition, a patient who was optimally treated with asingle vitamin or pair of vitamins might subsequently develop adeficiency of one or even two of the other vitamins as evidenced by are-elevation or increase in the levels of one or more metabolites.Therapeutic testing could be reinitiated and continued as describedabove, although this would also be time-consuming and expensive.

It requires less time and expense to treat patients with elevatedmetabolite levels with a combination of vitamin B₁₂ and folate, or acombination of vitamin B₁₂, folate and vitamin B₆. The utility of theapproach of the present invention is appreciated only after it istaught, for the first time in the present disclosure, that a deficiencyof one or more of the three vitamins occurs commonly in the elderlypopulation as evidenced by elevation of one or more metabolites, i.e.,MMA, 2-MCA, HC and CT.

EXAMPLE 5. Determination of Serum B₁₂, Folate, MMA, and HC Levels in aGeriatric Population.

A study was conducted with 548 elderly subjects from the Framinghamstudy between the ages of 65-99 to determine serum B₁₂, folate, MMA, andHC levels (Table 4). The significance of the results shown in Table 4(marked with "**") are as described for Table 2 (Example 2).

As in the study described in Examples 3 and 4, the elderly populationexhibited a shift to lower serum B₁₂ levels (FIG. 11), and elevatedserum MMA and HC levels. The elderly population also exhibited a highincidence (9.5%) of low serum folate levels (Table 4). As in the studiesreported in Examples 2, 3 and 4, the incidence of tissue orintracellular vitamin deficiencies based on elevated metabolite levelswas higher than that predicted from measurement of serum vitamin levels.

As in Examples 3 and 4 above, these results confirm the importance ofthe finding that there are a large number of patients with serumB₁₂ >300 pg/ml who have elevated values for one or more metabolites asindicated by a "**" next to the individual values. As is seen in Table4, there are many examples of elevated MMA values at all levels of serumB₁₂ including the mid-normal (300-600 pg/ml), the high-normal (600-800pg/ml), and even the elevated (>800 pg/ml) ranges. The same is true forelevations of HC. In some patients the serum folate is low, indicatingthat folate deficiency may be present, but in many cases both B₁₂ andfolate levels are normal. B₆ levels were not performed in this study,but B₆ deficiency would not be expected to cause elevations of MMA.Thus, again it is not clear which vitamin, or pair of vitamins, orwhether all three vitamins is or are deficient. One could pick a singlevitamin with which to treat a patient for several weeks or months, andthen repeat measurement of metabolite levels to determine if a partialor full correction had occurred. If there was no response, one could tryanother vitamin, or if there was a partial response one could add asecond vitamin, and then repeat metabolite measurement after severalweeks or months. If there was still no response, one could try the thirdvitamin, or if there was a partial response, one could try a differentpair of vitamins. Eventually one could determine whether an individualvitamin, a particular pair of vitamins, or all three vitamins wererequired to normalize or maximally reduce the metabolite levels, but itwould often require months or even a year to make this determination.Such a determination would be expensive. In addition, a patient who wasoptimally treated with a single vitamin or pair of vitamins mightsubsequently develop a deficiency of one or even two of the othervitamins as evidenced by a re-elevation or increase in the levels of oneor more metabolites. Therapeutic testing could be reinitiated andcontinued as described above, although this would also be time-consumingand expensive.

It requires less time and expense to treat patients with elevatedmetabolite levels with a combination of vitamin B₁₂ and folate, or acombination of vitamin B₁₂ folate and vitamin B₆. The utility of theapproach of the present invention is appreciated only after it istaught, for the first time in the present disclosure, that a deficiencyof one or more of the three vitamins occurs commonly in the elderlypopulation as evidenced by elevation of one or more metabolites, i.e.,MMA, 2-MCA, HC and CT.

                                      TABLE 2                                     __________________________________________________________________________    SERUM METABOLITE & VITAMIN LEVELS IN A GERIATRIC OUTPATIENT                   POPULATION.                                                                   Patient                                                                            B12  Folate                                                                             Homocysteine                                                                         MMA   CT   Total MC                                     __________________________________________________________________________    116    66**                                                                             9.8  41.8**  1508**                                                                              507**                                                                              759**                                       118    79**                                                                             9.3  29.6**  2200**                                                                              343**                                                                              428**                                       016   155**                                                                             7.6  15.3    1316**                                                                             208  196                                          067   163**                                                                             6.6  9.9     93   164   69                                          091   178**                                                                             12.0 29.2**  3108**                                                                              438**                                                                              318**                                       042   181**                                                                             11.3 13.0    452**                                                                              300   262**                                       030   185**                                                                             6.6  26.0**  282**                                                                              310  223                                          037   187**                                                                             9.4  12.3   160   218   334**                                       100   187**                                                                             9.5  13.6   208    453**                                                                             141                                          036   188**                                                                             9.9  16.3**  298**                                                                               385**                                                                              322**                                       109   189**                                                                             7.6  12.3   127   188  161                                          007   191**                                                                             11.7 67.1**  6349**                                                                              619**                                                                              1005**                                      018   193**                                                                             5.8  16.7**  412**                                                                              272   235**                                       050  210  4.0  25.3**  464**                                                                               727**                                                                             121                                          108  214  6.0  31.1** 264    523**                                                                              315**                                       041  216  7.2  19.1**  418**                                                                               360**                                                                              288**                                       126  224  6.5  8.8    103    361**                                                                             121                                          005  231  12.5 17.1** 269    825**                                                                              276**                                       024  235  13.0 18.5**  2946**                                                                             232   289**                                       111  237  6.3  14.6   135    380**                                                                             203                                          023  239  4.1  21.9**  385**                                                                               775**                                                                              279**                                       010  256  12.9 11.5    652**                                                                              119  144                                          055  258  6.8  7.5    189   342  185                                          102  259  10.9 23.9**  1894**                                                                              423**                                                                              400**                                       026  260  18.5 20.4**  1949**                                                                             295   248**                                       107  262  13.1 10.1   231    628**                                                                             153                                          038  269  7.6  15.7   222   152  152                                          140  277  4.0  29.1**  744**                                                                               602**                                                                              254**                                       074  278  5.2  24.1**  699**                                                                              296  187                                          002  278  14.6 14.8    554**                                                                              259   277**                                       019  282  8.5  12.4    329**                                                                              262  161                                          035  287  5.8  9.8    230    390**                                                                             218                                          049  290  3.9  33.0** 140   275  138                                          078  290  10.9 12.5   197   240  209                                          045  291  8.7  9.5    162    613**                                                                             132                                          092  294  14.9 19.3**  500**                                                                              246  167                                          137  297  6.8  10.1    631**                                                                              340  184                                          072  298  6.7  19.7**  375**                                                                              302   246**                                       149  310  8.3  16.1    314**                                                                              199  149                                          047  312  4.9  15.9    277**                                                                              271  173                                          060  312  9.4  8.0    100   228  203                                          046  314  6.5  16.2   142   336  125                                          093  318  6.4  16.5**  304**                                                                               361**                                                                             130                                          014  321  14.5 10.7    275**                                                                              233  170                                          088  327  7.1  17.8** 263    507**                                                                              258**                                       032  340  6.6  8.6    150   133  133                                          147  347  7.6  18.2**  305**                                                                              219   265**                                       001  351  4.7  20.8** 199    402**                                                                             223                                          090  353  4.9  20.7** 144    419**                                                                             178                                          008  358  5.4  11.6    372**                                                                               529**                                                                             177                                          104  360  12.7 12.1   260    89   77                                          110  370  3.0**                                                                              17.1**  456**                                                                              297  150                                          103  371  18.7 14.5   257   219  180                                          056  373  6.5  12.4   236    415**                                                                             189                                          048  374  3.6**                                                                              9.7    167   237   230**                                       131  377  10.9 13.6   256   220   85                                          122  378  7.6  21.9**  906**                                                                              227  196                                          004  385  8.6  10.3   109   288   92                                          120  390  9.8  22.9**  499**                                                                               529**                                                                              260**                                       138  405  6.9  14.7    334**                                                                              238  188                                          141  407  8.1  14.3   168   259   263**                                       101  408  5.9  9.2    160   134   40                                          145  410  3.7**                                                                              25.4**  567**                                                                               550**                                                                              349**                                       027  415  11.1 10.6   169   278  164                                          028  418  5.6  34.6**  608**                                                                               589**                                                                              351**                                       011  420  10.6 18.8**  683**                                                                               1014**                                                                             282**                                       081  421  6.6  16.5**  861**                                                                               641**                                                                              531**                                       033  423  4.2  16.3** 156   194  170                                          057  425  18.3 13.5   209    381**                                                                              321**                                       021  427  18.9 12.1   223    524**                                                                             168                                          135  430  8.8  13.5    284**                                                                               412**                                                                             180                                          097  435  15.4 10.9    353**                                                                               465**                                                                             119                                          052  438  6.8  15.2    281**                                                                               372**                                                                              238**                                       132  448  12.6 16.8**  1931**                                                                              394**                                                                              250**                                       086  451  12.1 6.6    139   208  107                                          148  458  13.9 11.4   187   322   238**                                       012  466  15.3 8.3     560**                                                                              250  144                                          083  466  12.0 13.7    366**                                                                              214  193                                          133  470  13.8 10.8    290**                                                                              275   55                                          017  475  4.0  39.6** 196    467**                                                                             220                                          053  476  13.4 12.3   226   206  125                                          009  482  6.5  25.3** 240    470**                                                                             214                                          066  498  9.6  12.9    374**                                                                              233   92                                          031  507  11.0 14.8   173   278  220                                          099  507  10.4 9.6    124   233   63                                          128  507  4.6  9.4     294**                                                                              324  176                                          013  514  11.3 15.9   163                                                     151  522  7.8  14.3    370**                                                                              324  215                                          077  523  6.8  17.7** 184   210  214                                          079  523  15.6 13.0    316**                                                                              223   251**                                       054  524  4.9  10.0   148   230  123                                          020  524  9.9  14.2   235    366**                                                                             190                                          069  528  7.0  9.7    257   281   83                                          085  536  4.0  22.5**  97   191  114                                          084  551  14.2 12.5   166   179  131                                          082  559  12.3 14.6   208    371**                                                                             182                                          117  560  3.4**                                                                              18.8** 102   176   88                                          061  561  12.7 9.8    170    404**                                                                             152                                          006  567  4.6  16.8** 138    688**                                                                             165                                          129  567  4.9  16.2    363**                                                                               495**                                                                              331**                                       003  570  11.4 12.9   189   330   230**                                       115  576  6.3  17.8* *                                                                              128   231   95                                          089  578  10.3 12.0   147   258   236**                                       143  581  2.6**                                                                              42.7** 165    555**                                                                             208                                          114  583  5.1  16.6**  599**                                                                               660**                                                                             177                                          080  593  9.5  18.0** 208   289  142                                          015  598  7.0  12.4   167    381**                                                                              95                                          039  598  9.6  18.1**  691**                                                                               719**                                                                              354**                                       070  612  5.6  13.7   197   296   82                                          051  622  12.9 8.3    119   246  150                                          139  628  8.5  7.8    145   166   83                                          150  628  8.6  14.5    295**                                                                              315  183                                          043  635  5.9  13.7   239   272  189                                          096  651  17.4 9.7     326**                                                  073  657  7.0  9.5    186   283   78                                          127  665  5.8  8.1    166    344**                                                                             147                                          121  677  10.2 9.5    226    346**                                                                             173                                          034  694  15.9 12.1    406**                                                                               592**                                                                              584**                                       124  697  9.7  11.0    63   179   60                                          123  702  10.4 10.6   186   148   96                                          113  705  7.6  8.4    107    534**                                                                              92                                          071  709  10.6 11.3   207    584**                                                                             141                                          076  722  8.1  10.5   271    489**                                                                             138                                          044  724  7.3  12.1   212    683**                                                                             217                                          040  731  15.1 7.4    205   149  136                                          062  741  4.4  18.7** 153    856**                                                                              416**                                       025  741  10.0 12.2   224    344**                                                                             121                                          119  755  5.9  10.1   187    377**                                                                              61                                          075  757  10.0 24.7** 246    345**                                                                              276**                                       098  759  13.8 13.9    380**                                                                              239  156                                          134  769  7.5  10.4   125   131   81                                          087  773  25.0 10.1   181   285  135                                          142  788  4.6  12.1   166   273  129                                          064  792  15.4 8.6    218   299  139                                          094  793  16.6 10.0   186   179  173                                          022  808  8.8  14.4   184   271  161                                          112  812  12.0 9.2    181   184  108                                          125  817  14.4 11.0   158   242   72                                          106  862  5.3  9.2     94   300   95                                          146  890  13.9 11.9   135                                                     058  897  5.3  18.5** 154    460**                                                                              80                                          063  943  17.8 19.7**  277**                                                                               642**                                                                              306**                                       095  960  25.3 10.7   135   181  111                                          152  963  9.4  8.8    198                                                     130  971  15.9 13.5   106   307   84                                          059  1063 9.4  9.7    129    378**                                                                              54                                          105  1109 11.0 6.1     87   155   64                                          136  1163 6.0  13.1   250    565**                                                                             122                                          065  1251 14.5 10.7    88   147   88                                          029  1490 22.2 9.7    129   111  105                                          144  1536 7.0  17.7** 216    694**                                                                              418**                                       068  1809 12.7 10.4    59   128   39                                          __________________________________________________________________________

                  TABLE 3                                                         ______________________________________                                        SERUM METABOLITE & VITAMIN LEVELS IN A GERIATRIC                              NURSING HOME POPULATION.                                                      Patient                                                                             B12       Folate  Homocysteine                                                                            Methylmalonic Acid                          ______________________________________                                        NH170   8**     14.0    34.8**     3365**                                     NH129   40**    7.4     40.9**     6245**                                     NH156   44**    22.4    17.4**     1130**                                     NH139   56**    9.7     20.9**     1180**                                     NH132   67**    7.6     92.4**    12641**                                     NH176  129**    9.2     20.3**     1156**                                     NH196  136**    6.2     41.0**     1077**                                     NH109  139**    9.8     20.9**     1294**                                     NH203  146**    4.3     12.2       437**                                      NH141  161**    13.4    12.2      223                                         NH178  172**    8.2     5.9       141                                         NH103  189**    5.5     13.1       362**                                      NH181  196**    6.3     14.7       296**                                      NH160 206       11.9    12.5       640**                                      NH197 221       24.0    10.5       654**                                      NH073 222       3.6**   19.8**     490**                                      NH110 227       5.5     13.7       1297**                                     NH010 228       4.0     21.1**     413**                                      NH012 234       8.7     16.0       596**                                      NH037 236       11.5    22.5**    11299**                                     NH114 238       12.8    13.2       442**                                      NH211 240       6.0     14.1      166                                         NH075 250       9.3     12.1      170                                         NH172 255       7.2     14.4       552**                                      NH148 259       5.7     19.2**     317**                                      NH138 264       9.2     16.7**     340**                                      NH150 264       4.0     13.7       98                                         NH099 272       5.5     12.5      125                                         NH124 275       6.9     11.5       87                                         NH179 301       7.6     7.1       143                                         NH135 302       6.5     23.4**     397**                                      NH087 304       7.8     10.8       327**                                      NH180 304       5.8     10.5      237                                         NH209 306       7.6     11.9      105                                         NH107 310       3.3**   8.6       148                                         NH081 320       4.3     23.6**     470**                                      NH068 324       7.9     13.4      243                                         NH183 325       7.7     11.1      144                                         NH033 330       13.8    7.7       149                                         NH161 333       8.5     11.3       385**                                      NH192 337       10.7    9.5       209                                         NH136 340       6.7     18.2**     409**                                      NH191 342       20.2    13.4      271                                         NH137 343       4.0     15.6      183                                         NH182 346       8.2     14.4       448**                                      NH020 347       8.4     10.4      149                                         NH165 351       18.5    11.8       425**                                      NH095 352       8.5     14.5       366**                                      NH194 361       4.3     20.3**     305**                                      NH106 362       4.8     12.9       298**                                      NH060 367       4.7     16.4**     71                                         NH009 368       5.1     15.9       325**                                      NH071 382       4.9     12.9       330**                                      NH080 390       6.1     15.0      171                                         NH013 407       6.7     12.4       310**                                      NH126 409       9.2     17.4**    137                                         NH030 411       11.2    10.4       844**                                      NH210 413       8.6     11.9      210                                         NH158 414       5.7     16.2       508**                                      NH027 416       10.2    15.5       769**                                      NH003 424       16.5    9.5       167                                         NH187 429       4.7     8.8        439**                                      NH022 430       10.5    14.0      214                                         NH082 436       10.6    17.7**     340**                                      NH162 438       6.1     19.2**    180                                         NH021 439       5.3     15.1      191                                         NH056 447       11.7    10.9      184                                         NH119 448       3.2**   14.1      241                                         NH120 448       5.6     12.0      138                                         NH186 450       4.7     23.1**    213                                         NH064 451       6.9     10.6      237                                         NH057 453       14.6    10.4       282**                                      NH131 454       8.1     16.2      258                                         NH059 462       6.0     9.1       147                                         NH202 465       3.3**   17.0**     393**                                      NH134 475       15.3    11.6       321**                                      NH083 475       7.4     10.6      178                                         NH199 479       15.1    10.4      141                                         NH042 482       6.0     15.0      141                                         NH200 491       13.6    9.8       154                                         NH213 497       8.1     10.0       92                                         NH143 500       5.2     22.1**    175                                         NH031 502       6.4     16.1      151                                         NH188 504       12.5    15.1       1461**                                     NH171 504       10.7    12.9       344**                                      NH008 505       4.6     9.9       185                                         NH102 506       16.6    9.1       236                                         NH145 512       7.7     22.2**    161                                         NH093 514       5.1     17.7**    185                                         NH118 524       25.0    10.1       314**                                      NH185 524       8.7     12.1       84                                         NH111 527       5.1     18.4**    250                                         NH149 530       12.6    18.2**     531**                                      NH011 534       8.1     12.5       654**                                      NH128 540       4.3     11.6      120                                         NH035 547       7.5     9.8       193                                         NH005 551       17.7    5.0        365**                                      NH212 552       11.9    12.1      202                                         NH007 554       6.4     26.1**     646**                                      NH086 554       9.5     5.1       127                                         NH069 555       22.7    6.8       134                                         NH121 555       8.2     10.0      112                                         NH117 571       6.6     9.7        351**                                      NH055 581       14.8    9.1       265                                         NH025 581       5.2     15.3      181                                         NH104 583       3.9     14.6       1699**                                     NH173 583       11.2    10.6      160                                         NH177 584       6.2     5.7       111                                         NH207 586       8.5     16.4**    243                                         NH070 591       5.4     12.0      168                                         NH038 592       8.0     8.8       230                                         NH049 599       10.7    21.7**    238                                         NH062 606       4.5     7.7        96                                         NH153 608       7.7     13.6      221                                         NH206 611       6.6     16.4**     400**                                      NH018 614       6.3     10.9      123                                         NH163 616       5.0     9.6       132                                         NH189 619       7.6     12.0      158                                         NH045 620       21.0    12.4      265                                         NH074 621       10.2    9.2       172                                         NH054 623       8.0     9.8       121                                         NH152 625       8.2     7.8       206                                         NH140 637       21.7    13.6       300**                                      NH050 642       16.3    13.5       275**                                      NH089 644       7.7     16.7**     444**                                      NH036 649       7.9     10.7       68                                         NH097 651       6.6     13.4       426**                                      NH016 656       4.1     61.0**     356**                                      NH053 657       14.2    10.6       320**                                      NH066 658       7.7     11.4      228                                         NH051 659       4.0     10.7      216                                         NH108 671       5.8     24.0**     823**                                      NH058 673       6.0     11.2       392**                                      NH028 675       22.3    9.1       105                                         NH204 678       4.7     10.2      148                                         NH169 679       6.9     19.2**    267                                         NH032 681       12.7    5.9        99                                         NH065 682       11.0    13.5      176                                         NH061 683       13.4    9.6       190                                         NH116 685       9.0     7.5       244                                         NH015 699       6.8     16.8**    236                                         NH157 711       10.0    12.8      198                                         NH155 715       10.0    17.6**     308**                                      NH034 715       7.9     11.4      179                                         NH040 717       10.5    15.7      256                                         NH105 718       6.0     13.2       308**                                      NH048 719       8.0     10.8      207                                         NH084 720       6.8     9.4       169                                         NH115 724       16.3    9.4       161                                         NH205 734       8.5     13.3      232                                         NH113 738       11.7    10.3      171                                         NH154 738       13.7    9.6       123                                         NH167 741       17.0    6.6       129                                         NH190 752       5.2     14.1      254                                         NH067 760       22.5    9.5       232                                         NH014 767       8.9     7.3       100                                         NH072 768       8.3     6.9       131                                         NH133 772       8.8     20.4**    219                                         NH122 778       6.0     10.4      108                                         NH076 781       12.1    14.9       282**                                      NH147 785       7.5     24.5**     411**                                      NH026 786       9.7     8.3       146                                         NH151 789       24.4    11.1      182                                         NH198 797       10.9    10.7      158                                         NH088 801       6.4     18.3**    184                                         NH004 806       11.3    8.8        96                                         NH024 818       5.1     14.1      219                                         NH100 826       16.4    10.5      103                                         NH078 831       7.2     10.3      266                                         NH052 844       19.6    8.0       193                                         NH142 848       18.6    12.1       398**                                      NH002 862       9.4     11.3      212                                         NH091 891       4.9     12.6      169                                         NH127 897       22.0    8.4       132                                         NH096 901       9.3     5.2       104                                         NH201 910       25.0    15.7       424**                                      NH184 941       21.5    10.8      170                                         NH208 945       20.2    9.8       111                                         NH130 968       22.4    10.4       339**                                      NH164 989       8.0     16.8**    102                                         NH077 1006      15.1    9.2       188                                         NH017 1015      11.9    9.5       175                                         NH029 1053      18.6    11.4      161                                         NH023 1055      9.3     9.7       193                                         NH047 1079      6.4     11.4      106                                         NH043 1082      14.5    13.9      144                                         NH195 1088      36.9    12.2      150                                         NH193 1092      8.2     15.7      225                                         NH046 1093      9.2     18.8**    186                                         NH101 1108      3.9     8.1       139                                         NH098 1117      11.3    12.5       88                                         NH168 1124      25.2    15.0      203                                         NH006 1126      6.9     8.1       159                                         NH144 1135      8.0     21.9**    262                                         NH044 1159      26.8    10.2      109                                         NH175 1162      7.8     12.0      210                                         NH146 1179      9.8     10.1      129                                         NH112 1238      10.3    15.0       347**                                      NH001 1304      13.1    6.9       142                                         NH166 1337      13.4    8.3        67                                         NH079 1346      18.0    12.0      248                                         NH041 1528      20.7    8.2       155                                         NH063 1559      15.0    7.0        66                                         NH159 1566      6.6     15.5       451**                                      NH125 1703      8.2     20.6**    153                                         NH094 1768      15.9    8.4       182                                         NH123 2028      10.2    16.8**    206                                         NH174 2106      13.3    12.8       280**                                      NH039 2227      23.8    8.9       119                                         NH019 2297      11.1    15.5      177                                         NH092 2360      5.7     9.8       131                                         NH085 3141      22.0    26.9**     1947**                                     ______________________________________                                    

                  TABLE 4                                                         ______________________________________                                        SERUM METABOLITE AND VITAMIN LEVELS IN A                                      GERIATRIC POPULATION.                                                         Patient B.sub.12 Folate    Homocysteine                                                                           MMA                                       ______________________________________                                        495       77**   10.0      65.4**    3145**                                   484       84**   10.0      77.5**    6820**                                   522      100**   3.6**     15.5      967**                                    455      115**   1.9**     21.8**   170                                       493      135**   4.4       16.9**    421**                                    528      145**   3.9       38.3**    729**                                    510      155**   4.6       14.1      804**                                    502      155**   2.1**     16.9**    347**                                    412      160**   18.5      33.8**    1301**                                   409      160**   4.8       16.8**   164                                       470      165**   9.2       19.9**    1468**                                   460      165**   6.8       11.5     142                                       437      170**   4.9       16.5**    813**                                    439      170**   1.2**     21.3**    502**                                    525      175**   11.5      15.3      1058**                                   442      175**   4.2       17.5**    328**                                    456      180**   7.3       11.1     206                                       450      180**   5.0       11.8     196                                       477      185**   3.4**     31.4**    369**                                    508      190**   4.1       19.5**    335**                                    423      190**   2.5**     19.0**    329**                                    462      190**   3.8       11.6      276**                                    523      190**   5.6       16.8**   207                                       482      190**   2.9**     25.1**   179                                       459      190**   5.3       19.6**   167                                       543      195**   4.3       13.5      470**                                    520      195**   1.7**     22.2**    309**                                    431      195**   7.2       13.5     251                                       513     200      5.0       25.0**    1184**                                   534     200      4.9       32.6**    1080**                                   515     200      4.9       17.3**    478**                                    531     200      5.1       26.8**    466**                                    516     200      3.6**     17.8**    279**                                    526     200      1.6**     23.5**   171                                       471     205      5.7       22.0**    542**                                    413     205      2.6**     20.4**    304**                                    497     205      3.3**     19.4**   258                                       539     205      4.1       15.4     247                                       544     205      12.5      11.7     233                                       540     205      4.0       17.1**   185                                       517     205      2.2**     15.0     151                                       496     210      3.7**     15.2      1103**                                   488     210      16.5      21.8**    600**                                    416     215      12.5      10.0     197                                       434     220      7.1       24.8**    439**                                    545     220      11.5      14.4      407**                                    547     220      5.3       17.5**    396**                                    408     220      3.2**     16.4**    357**                                    449     220      3.7**     13.7      272**                                    507     220      8.5       10.0     179                                       458     225      10.5      21.1**    964**                                    491     225      7.2       16.0      472**                                    529     230      2.0**     61.1**    1172**                                   415     230      3.2**     28.9**    377**                                    453     230      3.6**     19.8**    336**                                    448     230      5.2       13.1      319**                                    498     230      5.9       20.1**   255                                       533     230      5.7       11.7     151                                       466     235      35.0      12.1      617**                                    537     235      5.7       10.7      394**                                    483     235      8.6       16.6**    344**                                    512     235      3.9       12.5     190                                       452     240      4.7       26.5**    1068**                                   454     240      5.2       11.9     201                                       535     240      4.4       15.3     195                                       421     245      10.5      12.5      464**                                    469     245      6.2       20.0**    448**                                    474     245      7.3       10.3      327**                                    486     245      9.2       12.6     156                                       536     250      22.5      20.3**    1068**                                   475     250      5.6       23.0**    456**                                    511     250      2.7**     23.1**    398**                                    465     250      4.1       23.1**    323**                                    506     250      5.2       11.5     252                                       417     250      5.5       25.2**   241                                       524     250      2.5**     14.4     212                                       411     250      9.9       11.5     200                                       492     250      5.2       10.7     182                                       548     250      2.9**     12.4     179                                       441     250      4.5       8.5      147                                       480     255      4.8       16.9**    558**                                    532     255      7.0       14.8      419**                                    464     255      11.5      12.9      400**                                    494     255      6.2       12.1      293**                                    106     255      4.5       11.7     203                                       546     260      5.5       14.7      662**                                    541     260      5.4       30.8**    426**                                    420     260      5.3       13.6      347**                                    500     260      6.7       14.0      330**                                    538     260      9.3       17.3**    298**                                    457     260      2.9**     12.6      286**                                    472     260      8.3       13.8      278**                                    424     260      8.3       10.1     242                                       433     260      6.8       10.5     197                                       425     265      7.3       14.7      724**                                    468     265      3.8       16.7**    289**                                    435     265      7.4       14.0     150                                       499     265      2.2**     12.4     131                                       432     270      4.3       28.3**    432**                                    521     270      3.7**     15.3      349**                                    549     270      4.1       12.4      343**                                    518     270      10.0      10.1      276**                                    418     270      26.0      9.4      213                                       419     270      6.5       12.5     212                                       428     270      4.2       18.7**   189                                       443     270      8.8       12.0     187                                       446     270      11.0      8.1      157                                       461     275      7.6       15.1      663**                                    440     275      4.9       12.9     248                                       436     275      6.3       30.1**   233                                       530     275      7.4       13.6     231                                       438     275      4.6       8.5      221                                       527     275      7.5       10.5     219                                       444     275      4.0       12.2     180                                       429     280      5.3       15.3      463**                                    503     280      4.4       25.7**    421**                                    485     280      3.5**     15.6      381**                                    410     280      14.5      10.0     201                                       487     280      3.9       10.5     166                                       430     280      9.2       8.8      161                                       519     285      3.9       22.2**    919**                                    476     285      10.5      12.8      339**                                    509     285      5.4       13.0      331**                                    501     285      5.5       12.4     252                                       542     285      6.9       15.5     242                                       445     285      7.2       14.9     237                                       427     285      4.0       17.1**   233                                       490     290      4.7       13.9     230                                       451     290      2.1**     20.0**   226                                       414     290      7.0       9.7      117                                       467     290      4.1       6.5       68                                       463     295      5.8       12.3      296**                                    473     295      7.5       14.4      290**                                    505     295      4.1       12.4     257                                       198     300      11.5      10.9      323**                                    195     300      9.8       12.2     216                                       207     305      7.7       13.2      330**                                    67      305      8.6       15.4      312**                                    50      305      9.0       11.6     235                                       70      305      12.5      12.7     228                                       113     305      5.6       13.5     201                                       39      305      6.9       19.7**   170                                       3       305      4.2       11.5     135                                       325     305      14.5      9.4       94                                       368     310      4.7       15.9      371**                                    322     310      7.8       15.3      362**                                    295     310      7.2       13.8      305**                                    347     310      5.8       16.5**   266                                       313     310      6.1       16.5**   219                                       355     310      5.5       15.4     138                                       291     310      4.5       15.2     125                                       478     315      23.0      17.7**    857**                                    53      315      5.8       12.1      505**                                    240     315      6.7       12.3      394**                                    14      315      9.6       14.2      331**                                    137     315      7.8       24.3**    306**                                    254     315      8.7       17.0**    285**                                    109     315      3.7**     16.5**   263                                       252     315      5.2       10.1     241                                       186     315      4.1       15.4     238                                       183     315      5.5       10.7     195                                       390     315      6.9       10.0     188                                       267     315      2.2**     12.0     124                                       310     320      12.0      13.8      395**                                    31      320      17.0      12.9      334**                                    88      320      4.8       13.8     217                                       403     320      9.6       11.3     162                                       60      320      6.2       11.4     155                                       315     320      6.4       9.9      136                                       175     325      6.3       17.8**    486**                                    317     325      22.0      14.0      294**                                    18      325      6.3       11.1     241                                       247     325      13.5      13.2     231                                       223     325      9.2       12.6     203                                       132     325      3.7**     15.4     184                                       168     325      4.3       10.2     174                                       238     325      5.5       9.9      166                                       117     325      5.2       15.0     154                                       404     330      2.5**     33.1**    1085**                                   138     330      4.8       11.3      360**                                    316     330      3.6**     10.2      272**                                    61      330      5.1       12.5     242                                       333     330      34.0      9.2      235                                       16      330      4.6       13.3     211                                       276     330      5.7       11.9     200                                       391     330      4.1       8.4      184                                       362     330      9.2       11.7     178                                       1       330      9.9       8.9      170                                       379     335      16.0      12.1      471**                                    147     335      9.0       9.7       427**                                    89      335      8.0       15.3      385**                                    211     335      5.0       12.2      374**                                    45      335      5.9       16.3**   250                                       47      335      5.0       13.6     249                                       402     335      4.7       13.5     230                                       314     335      7.6       9.7      203                                       150     335      4.8       11.2     119                                       120     340      1.9**     21.0**    775**                                    284     340      7.2       25.6**    439**                                    230     340      14.0      11.4      419**                                    149     340      8.8       18.9**    337**                                    269     340      3.9       16.2      302**                                    197     340      10.5      12.8     233                                       19      340      9.6       11.0     232                                       422     340      3.1**     14.4     188                                       196     340      11.5      8.9      169                                       40      345      8.7       14.6      610**                                    244     345      8.6       15.8      461**                                    287     345      5.7       18.1**    427**                                    100     345      8.3       14.8      403**                                    383     345      4.3       27.2**    284**                                    62      345      19.5      9.6      250                                       350     345      8.0       10.0     249                                       65      345      8.0       10.2     247                                       307     345      16.5      11.6     208                                       69      345      17.0      9.9      197                                       328     345      7.5       8.9      192                                       43      345      6.0       13.2     191                                       222     345      6.1       9.2      175                                       306     345      4.3       17.2**   160                                       154     345      7.1       10.2     148                                       94      350      4.8       16.1      302**                                    201     350      6.1       9.9      200                                       13      350      5.1       10.9     193                                       236     355      7.2       14.8      309**                                    191     355      5.8       15.3     257                                       481     355      5.2       17.1**   134                                       92      360      4.2       25.2**    321**                                    324     360      3.8       16.6**   264                                       87      360      3.3**     13.3     200                                       46      360      5.4       11.1     179                                       289     360      9.5       7.9      129                                       392     360      5.1       10.3     125                                       320     365      6.4       17.3**   240                                       134     365      13.5      11.8     238                                       239     365      7.7       13.2     236                                       326     365      6.0       10.9     180                                       364     365      4.1       13.9     154                                       218     365      7.5       11.2     126                                       216     365      6.2       12.2     119                                       248     365      5.7       13.3     117                                       375     370      4.1       20.7**    532**                                    288     370      6.4       18.8**    436**                                    161     370      6.3       11.2      340**                                    224     370      19.5      9.8       286**                                    330     370      18.0      12.2     228                                       334     370      12.5      8.7      172                                       275     370      6.9       12.7     162                                       54      375      7.3       10.1      583**                                    185     375      9.3       10.5      386**                                    52      375      8.1       15.5      291**                                    366     375      5.0       12.5      280**                                    93      375      3.3**     16.2     248                                       151     375      2.9**     12.3     235                                       85      375      6.7       14.8     217                                       294     375      7.0       12.2     184                                       361     375      7.9       10.7     179                                       318     375      5.5       13.7     160                                       386     375      7.6       10.4     153                                       304     375      9.1       9.4      132                                       228     380      7.7       17.1**    320**                                    110     380      4.0       7.2      135                                       204     380      5.7       10.6      91                                       348     385      2.3**     17.4**    368**                                    146     385      11.5      12.5     253                                       260     385      5.5       13.7     211                                       136     385      3.6**     19.8**   205                                       338     385      5.0       16.2     180                                       376     385      3.6**     13.7     154                                       194     385      12.5      7.9      153                                       504     385      38.0      9.5      138                                       160     390      8.1       24.7**    475**                                    354     390      11.5      12.8     212                                       25      390      5.1       11.3     205                                       387     390      8.7       8.4      162                                       86      390      21.0      12.6     133                                       133     390      3.9       11.3     113                                       331     395      12.0      20.1**    638**                                    130     395      10.5      10.8     256                                       82      395      2.8**     9.8      236                                       119     395      12.5      16.3**   209                                       380     395      10.5      14.3     159                                       373     395      5.5       11.6     152                                       256     395      10.5      9.9      149                                       384     395      7.3       14.7     116                                       105     400      19.0      10.5      322**                                    251     400      4.8       14.9      289**                                    352     400      11.5      9.6      181                                       279     400      4.5       11.7     170                                       339     400      7.4       13.6     168                                       381     405      6.7       12.4      294**                                    285     405      7.0       14.2      281**                                    340     405      3.6**     19.6**    275**                                    51      405      6.5       14.3     233                                       33      405      6.5       9.6      207                                       268     405      3.3**     14.9     205                                       73      405      5.2       13.1     172                                       17      410      7.5       16.2      473**                                    286     410      4.7       18.8**    415**                                    140     410      5.9       21.7**    302**                                    116     410      6.8       14.5     218                                       396     410      5.6       16.1     190                                       356     410      1.9**     27.6**   149                                       237     410      3.6**     16.6**   122                                       112     410      5.5       8.9      107                                       259     410      4.7       11.6      99                                       176     415      5.2       21.9**    453**                                    193     415      10.5      11.3     163                                       323     415      6.1       9.6      163                                       202     415      11.5      9.4      150                                       398     415      8.0       12.6     134                                       321     420      5.2       10.7      383**                                    142     420      29.0      8.3      234                                       327     420      3.2**     14.6     203                                       342     420      7.3       9.4      156                                       170     420      20.5      10.3     142                                       345     420      29.5      13.2     136                                       302     420      8.6       8.8      128                                       115     425      6.3       22.2**    628**                                    97      425      12.5      19.8**    313**                                    246     425      8.7       15.1     241                                       72      425      10.5      13.5     241                                       365     425      6.7       16.7**   237                                       139     425      12.5      10.4     224                                       143     425      8.1       13.5     216                                       426     425      19.5      14.5     201                                       303     425      3.0**     14.5     154                                       388     425      6.2       12.3     135                                       127     425      6.7       8.4      100                                       262     430      10.0      12.1      323**                                    270     430      4.8       12.9      293**                                    514     430      4.3       12.9     197                                       341     430      3.5**     19.9**   190                                       278     430      5.2       10.8     182                                       370     430      11.0      15.3     174                                       55      430      7.6       11.0     162                                       274     430      5.0       8.2      131                                       367     430      17.5      8.0      126                                       98      430      13.5      12.8     125                                       337     435      13.5      14.1      395**                                    309     435      8.7       12.9      349**                                    305     435      17.5      15.4     187                                       144     435      25.0      8.9      167                                       34      435      8.6       7.6      157                                       234     435      9.7       9.2      116                                       123     440      9.6       12.2      622**                                    200     440      4.8       12.4     257                                       250     440      7.5       12.9     248                                       107     440      6.3       14.7     183                                       300     440      6.5       7.9      123                                       374     445      5.4       14.0     247                                       372     445      11.0      11.0     181                                       36      445      4.0       10.0     181                                       271     445      7.2       10.4     124                                       242     445      15.5      9.6      112                                       264     445      6.0       10.7     100                                       172     450      11.5      14.9      607**                                    32      450      11.5      13.6      362**                                    346     450      13.5      15.8      330**                                    41      450      8.5       11.4     194                                       95      450      5.1       12.5     182                                       357     455      6.3       14.4      296**                                    319     455      17.0      10.2     147                                       308     455      15.0      9.8      131                                       235     455      23.0      9.0      114                                       349     455      9.2       8.3       82                                       178     460      5.6       20.6**    473**                                    312     460      4.7       14.4     197                                       79      460      5.0       10.4     173                                       131     460      18.0      10.2     162                                       243     460      2.6**     11.6     160                                       261     465      7.7       10.6     252                                       378     465      5.4       13.2     221                                       49      465      47.0      10.8     179                                       226     465      7.7       10.2     173                                       377     465      5.6       8.5      143                                       253     465      10.0      7.0      138                                       76      470      12.5      14.8      304**                                    203     470      15.0      7.6      233                                       296     470      23.5      11.0     161                                       382     470      5.3       11.1     109                                       6       475      10.5      12.5     232                                       75      475      4.5       8.1      150                                       332     475      9.4       10.0     144                                       290     475      14.0      9.1      143                                       128     475      5.9       9.3      133                                       124     475      6.0       13.5     111                                       177     475      8.8       9.1      106                                       126     480      11.0      11.0     212                                       283     480      5.2       10.6     175                                       209     480      10.5      10.5     175                                       293     480      6.8       15.5     135                                       121     485      4.7       20.0**    345**                                    282     485      12.0      10.9     236                                       71      485      13.5      8.1      168                                       385     485      9.0       14.1     128                                       190     495      9.9       10.4      410**                                    210     495      8.6       12.0     243                                       155     495      5.9       10.4     219                                       336     495      13.5      9.9      135                                       280     500      8.7       14.5      334**                                    96      500      4.7       10.8     237                                       145     500      5.9       17.5**   233                                       199     500      4.2       13.8     199                                       489     500      11.5      9.7      198                                       217     500      6.4       9.6      166                                       90      500      7.5       8.5      106                                       164     510      5.2       23.8**    408**                                    343     510      4.5       13.7      284**                                    42      510      4.9       7.4      233                                       351     510      8.5       11.0     207                                       299     510      12.0      8.0      104                                       99      520      10.5      25.8**    322**                                    114     520      30.0      10.9     220                                       369     520      29.0      16.7**   206                                       37      520      10.5      8.6      191                                       215     520      6.7       16.8**   151                                       401     520      7.5       12.6     148                                       229     520      7.9       11.0     116                                       135     520      3.2**     8.3       88                                       81      530      6.8       14.8      372**                                    91      530      14.5      10.6     228                                       167     530      23.5      9.2      176                                       181     530      5.5       9.3      171                                       56      530      20.0      8.3      163                                       5       530      13.5      8.1      159                                       180     540      12.0      9.0      216                                       311     540      4.1       13.3     214                                       389     540      3.9       13.9     169                                       125     540      5.5       13.0     159                                       35      540      22.5      11.0     123                                       104     550      10.5      16.5**    544**                                    393     550      4.9       11.9      339**                                    394     550      23.0      14.0      278**                                    292     550      6.9       16.2     263                                       163     550      6.7       14.3     219                                       66      550      10.5      11.6     206                                       29      550      17.5      9.6      191                                       227     550      7.9       11.7     154                                       38      550      7.5       11.9     152                                       241     550      10.5      9.8      100                                       102     550      9.7       8.6       91                                       77      560      24.0      14.8      554**                                    162     560      10.5      11.8      275**                                    273     560      8.7       9.4      180                                       80      560      6.3       11.2     108                                       255     560      8.8       9.9       93                                       122     570      66.0      13.8      304**                                    208     570      34.0      10.2     255                                       23      570      21.5      8.3      241                                       447     570      25.0      10.0     164                                       225     570      5.7       12.2     154                                       174     570      7.1       11.0     127                                       11      570      19.0      8.9      113                                       165     580      10.5      14.8     226                                       182     580      8.9       8.2      189                                       245     590      15.5      10.0     262                                       83      590      17.5      8.3      199                                       166     590      11.5      9.4      188                                       158     590      7.3       10.7     166                                       187     590      4.5       11.0     146                                       156     590      23.5      11.3     112                                       231     600      9.5       9.0      192                                       78      600      11.5      9.4      151                                       329     610      15.0      7.3       312**                                    57      610      16.0      11.9      286**                                    7       610      12.0      10.4     195                                       277     610      9.5       7.8      153                                       108     620      13.5      8.4      191                                       205     620      18.0      7.5      145                                       263     620      9.8       10.2     101                                       9       630      4.9       11.4      300**                                    111     630      8.3       11.1      276**                                    68      630      11.5      8.9      143                                       399     630      14.0      11.0      90                                       266     640      5.1       15.7      364**                                    12      640      24.5      9.0      233                                       152     640      8.1       10.0     209                                       405     640      7.0       12.8     186                                       27      640      22.5      8.4      136                                       258     640      8.3       11.2     120                                       249     640      8.7       9.1       81                                       297     650      16.0      10.0      279**                                    192     650      4.9       14.9     213                                       257     650      3.3**     16.3**   208                                       184     650      12.5      9.9      193                                       58      650      18.5      10.7     172                                       301     650      16.0      15.5     162                                       397     650      12.5      8.4      146                                       272     650      11.0      7.4      120                                       153     650      7.1       13.1     116                                       406     650      6.6       5.8       81                                       10      660      9.0       7.6      154                                       26      660      22.0      8.3      132                                       265     670      3.9       19.3**    509**                                    359     670      21.0      8.3      269                                       48      670      32.0      9.9      262                                       335     670      11.5      8.1      121                                       189     680      6.6       17.9**    358**                                    220     680      15.5      10.9     115                                       15      690      13.5      13.4     159                                       44      700      20.0      12.7     244                                       21      700      13.5      10.2     129                                       74      700      15.0      7.1       65                                       4       710      29.0      8.5      266                                       353     710      11.5      11.4     206                                       281     710      10.5      9.6      185                                       2       710      8.0       8.5      109                                       212     740      20.0      11.1     250                                       8       740      12.0      11.5     216                                       206     750      12.5      8.3      116                                       101     770      14.5      12.7      372**                                    344     770      32.0      11.7      297**                                    20      770      35.0      10.1     245                                       407     770      10.5      12.0     110                                       360     780      2.7**     20.9**   157                                       232     790      15.5      10.1     151                                       141     790      12.5      9.5       74                                       129     800      8.7       11.7     211                                       188     800      15.0      12.3     174                                       400     800      12.5      10.3     156                                       24      810      23.0      7.5      194                                       173     830      35.0      11.4     243                                       214     830      21.5      12.0     187                                       63      830      13.8      8.8      185                                       148     830      45.0      7.1      146                                       84      830      23.5      7.0      136                                       179     830      16.5      6.6       96                                       171     840      23.5      11.2     195                                       28      870      5.8       15.9     197                                       233     870      7.9       12.7     169                                       221     870      40.0      7.0      126                                       371     880      20.0      8.5      152                                       213     890      10.5      18.0**   231                                       358     900      21.0      8.3      149                                       298     910      15.5      10.2     221                                       118     910      100.0     9.7      170                                       479     950      11.5      12.1     188                                       30      950      6.2       10.5     170                                       159     1000     9.5       8.7       281**                                    219     1050     37.0      14.3      313**                                    103     1050     12.5      10.3     154                                       59      1150     17.5      7.3      180                                       157     1250     12.0      14.0     206                                       363     1350     28.0      10.4     190                                       22      1400     13.5      10.4     233                                       64      1400     31.0      9.7      149                                       169     1450     15.0      9.5      150                                       ______________________________________                                    

I claim:
 1. A method of treating or preventing elevated serum metabolitelevels of at least one of homocysteine, methylmalonic acid,cystathionine, or 2-methylcitric acid comprising periodicallyadministering orally a single formulation having between 0.3-10 mgvitamin B₁₂ and 0.1-0.4 mg folic acid.
 2. The method of claim 1 whereinthe formulation includes approximately 2 mg vitamin B₁₂ and 0.4 mg folicacid.
 3. The method of claim 1 wherein said metabolite is homocysteine.4. The method of claim 1 wherein said metabolite is methylmalonic acid.5. The method of claim 1 wherein said metabolite is cystathionine. 6.The method of claim 1 wherein said metabolite is 2-methylcitric acid. 7.A method of treating or preventing elevated serum metabolite levels ofat least one of homocysteine, methylmalonic acid, cystathionine, or2-methylcitric acid comprising periodically administering orally asingle formulation having between 0.3-10 mg vitamin B₁₂, 0.1-0.4 mgfolic acid, and 5-75 mg B₆.
 8. The method of claim 7 wherein theformulation includes approximately 2 mg vitamin B₁₂ and 0.4 mg folicacid and 25 mg B₆.
 9. The method of claim 7 wherein said metabolite ishomocysteine.
 10. The method of claim 7 wherein said metabolite ismethylmalonic acid.
 11. The method of claim 7 wherein said metabolite iscystathionine.
 12. The method of claim 7 wherein said metabolite is2-methylcitric acid.
 13. A method of treating or preventing elevatedserum metabolic levels of at least one of homocysteine, methylmalonicacid, cystathionine, or 2-methylcitric acid comprising periodicallyadministering orally a single formulation having between 0.3-10 mgvitamin B₁₂ and 0.4-10.0 mg folic acid.
 14. The method of claim 13wherein the formulation includes approximately 2 mg vitamin B₁₂ and 1.0mg folic acid.
 15. The method of claim 13 wherein said metabolite ishomocysteine.
 16. The method of claim 13 wherein said metabolite ismethylmalonic acid.
 17. The method of claim 13 wherein said metaboliteis cystathionine.
 18. The method of claim 13 wherein said metabolite is2-methylcitric acid.
 19. A method of treating or preventing elevatedserum metabolite levels of at least one of homocysteine, methylmalonicacid, cystathionine, or 2-methylcitric acid comprising periodicallyadministering orally a single formulation having between 0.3-10 mgvitamin B₁₂, 0.4-10 mg folic acid, and 5-75 mg B₆.
 20. The method ofclaim 19 wherein the formulation includes approximately 2 mg vitamin B₁₂and 1.0 mg folic acid and 25 mg B₁₂.
 21. The method of claim 19 whereinsaid metabolite is homocysteine.
 22. The method of claim 19 wherein saidmetabolite is methylmalonic acid.
 23. The method of claim 19 whereinsaid metabolite is cystathionine.
 24. The method of claim 19 whereinsaid metabolite is 2-methylcitric acid.
 25. A method of lowering serummetabolite levels of at least one of homocysteine, methylmalonic acid,cystathionine, or 2-methylcitric acid comprising periodicallyadministering orally a single formulation having between 0.3-10 mgvitamin B₁₂, 0.1-0.4 mg folic acid.
 26. A method of claim 25 wherein theformulation includes approximately 2 mg vitamin B₁₂ and 0.4 mg folicacid.
 27. The method of claim 25 wherein said metabolite ishomocysteine.
 28. The method of claim 25 wherein said metabolite ismethylmalonic acid.
 29. The method of claim 25 wherein said metaboliteis cystathionine.
 30. The method of claim 25 wherein said metabolite is2-methylcitric acid.
 31. A method of lowering serum metabolite levels ofat least one of homocysteine, methylmalonic acid, cystathionine, or2-methylcitric acid comprising periodically administering orally asingle formulation having between 0.3-10 mg vitamin B₁₂, 0.1-0.4 mgfolic acid, and 5-75 mg B₆.
 32. The method of claim 31 wherein theformulation includes approximately 2 mg vitamin B₁₂ and 0.4 mg folicacid and 25 mg B₆.
 33. The method of claim 31 wherein said metabolite ishomocysteine.
 34. The method of claim 31 wherein said metabolite ismethylmalonic acid.
 35. The method of claim 31 wherein said metaboliteis cystathionine.
 36. The method of claim 31 wherein said metabolite is2-methylcitric acid.
 37. A method of lowering serum metabolite levels ofat least one of homocysteine, methylmalonic acid, cystathionine, or2-methylcitric acid comprising periodically administering orally asingle formulation having between 0.3-10 mg vitamin B₁₂ and 0.4-10.0 mgfolic acid.
 38. The method of claim 37 wherein the formulation includesapproximately 2 mg vitamin B₁₂ and 1.0 mg folic acid.
 39. The method ofclaim 37 wherein said metabolite is homocysteine.
 40. The method ofclaim 37 wherein said metabolite is methylmalonic acid.
 41. The methodof claim 37 wherein said metabolite is cystathionine.
 42. The method ofclaim 37 wherein said metabolite is 2-methylcitric acid.
 43. A method oflowering serum metabolite levels of at least one of homocysteine,methylmalonic acid, cystathionine, or 2-methylcitric acid comprisingperiodically administering orally a single formulation having between0.3-10 mg vitamin B₁₂, 0.4-10 mg folic acid, and 5-75 mg B₆.
 44. Themethod of claim 43 wherein the formulation includes approximately 2 mgvitamin B₁₂ and 1.0 mg folic acid and 25 mg B₆.
 45. The method of claim43 wherein said metabolite is homocysteine.
 46. The method of claim 43wherein said metabolite is methylmalonic acid.
 47. The method of claim43 wherein said metabolite is cystathionine.
 48. The method of claim 43wherein said metabolite is 2-methylcitric acid.